Question

question 15 of 15

medical necessity ensures that a service is:

guided by the principle called protocol of effectiveness
the least expensive intervention available
based on referral by an individuals physician
directly related to a medical condition determined by evaluation and diagnosis

Explanation:

Define Medical Necessity

Medical necessity in healthcare and Medicaid contexts refers to services, treatments, or supplies that are proper and needed for the diagnosis or treatment of a medical condition, meet the standards of good medical practice, and are not mainly for the convenience of the patient or provider.

Evaluate the options

• "Guided by the principle called Protocol of Effectiveness": This is not a standard regulatory definition or primary requirement for medical necessity.
• "The least expensive intervention available": While cost-effectiveness is considered, medical necessity does not strictly mandate the absolute cheapest intervention if it is clinically inappropriate.
• "Based on referral by an individual's physician": A referral alone does not automatically establish clinical medical necessity.
• "Directly related to a medical condition determined by evaluation and diagnosis": This directly aligns with the core definition of medical necessity, which requires services to address a specific diagnosed condition.

Answer:

• (A) Guided by the principle called Protocol of Effectiveness
• (B) The least expensive intervention available
• (C) Based on referral by an individual's physician
• (D) Directly related to a medical condition determined by evaluation and diagnosis (Correct answer)